Sharps Handling Practices Among Junior Surgical Residents – A Video Analysis David Tso BSc, Monica...
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Transcript of Sharps Handling Practices Among Junior Surgical Residents – A Video Analysis David Tso BSc, Monica...
Sharps Handling Practices Among Junior Surgical Residents – A Video AnalysisSharps Handling Practices Among Junior Surgical Residents – A Video AnalysisDavid Tso BSc, Monica Langer MD, Geoffrey Blair MD, Sonia Butterworth MDDavid Tso BSc, Monica Langer MD, Geoffrey Blair MD, Sonia Butterworth MD
Division of Pediatric General Surgery, BC Children’s HospitalDivision of Pediatric General Surgery, BC Children’s Hospital
INTRODUCTIONINTRODUCTIONA survey of surgical residents at over 17 medical centers found that 99% of surgeons in training had sustained a needlestick injury by their final year of training (2) 53% involved patients with a history of HIV, hepatitis B or C, or intravenous-drug use In differentiating the mechanisms of injuries due to sharps, Bakaeen and colleagues found that
69% of OR injuries were inflicted by suture needles 9% from hollow-bore needles 34% from sharp instruments (3)
Specifically, injuries from sharps can occur when Loading suture needle into driver/repositioning needle
with fingers During hand-to-hand passing of sharps Suturing muscle and fascia when needle manipulated
with fingers Retraction of tissue with hands Surgeon sews towards own hand or assistant's hand Tying a suture while needle is attached Suture is left unattended on operative field after use (4)
REFERENCESREFERENCES(1) O'Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among residents and medical students. Arch.Intern.Med. 1992 Jul;152(7):1451-1456. (2) Makary MA, Al-Attar A, Holzmueller CG, Sexton JB, Syin D, Gilson MM, et al. Needlestick injuries among surgeons in training. N.Engl.J.Med. 2007 Jun 28;356(26):2693-2699. (3) Bakaeen F, Awad S, Albo D, Bellows CF, Huh J, Kistner C, et al. Epidemiology of exposure to blood borne pathogens on a surgical service. Am.J.Surg. 2006 Nov;192(5):e18-21.
PURPOSEPURPOSETo examine sharps handling practices of junior surgical residents performing an operation Evaluate whether experience correlates with a decrease in unsafe sharps behavior
Hypothesis: Safety performance is not expected to improve with operative experience in the absence of formal training on sharps
practices
Sharps Task Safe UnsafePersonal Sharp Tasks
Suture needle Using forceps to load or reposition needle
Using fingers to load or reposition needle
Tying Sutures Needle is on driver during tying, and is protected
Needle is exposed while tying suture
Tissue Retraction Using instrument to retract wound edge when using sharps
Using hand/fingers to retract wound edge, when suturing towards hand/fingers
Injection Needle Handling
Injecting away from hand/fingers, no 2-handed needle re-capping
Injecting towards hand/fingers, 2 handed needle capping
Sharps Placement on Operative Field
Placing sharps back onto a neutral hands free zone while not in use
Sharps left on operative field unattended
Passing of SharpsPassing of Sharps Passing suture with
needle in driver handle first, scalpel handle first, use of neutral hands free zone
Passing of suture with needle exposed, blade first
Verbal NotificationVerbal notification when passing sharp instruments
Clear verbal notification when passing sharps
Unclear/No verbal notification when passing sharps
Table 1: Definitions of safe and unsafe sharps tasks used to assess safety performance
Resident safety performance was assessed in three areas:1. Personal sharps tasks
E.g. Suture needle handling2. Passage of sharps
E.g. Scalpel , injection needle3. Verbal notification when passing of sharps
E.g. “There’s a needle up.” Second video was taken of the resident after the technical
performance feedback session and safety performance was compared between the two procedures.
Video reviewer blinded to resident level & video order
01020
30405060
708090
100
Initial Video (n=8) Final Video (n=8)
personal passage communication
Figure 2. Graph of mean percentage of safe tasks performed by surgical residents as seen in the initial and final videos (n=8) taken during an inguinal hernia repair.
Description SafetyInitial video
(mean)
Standard Deviatio
nSuture needle manipulation
Safe 4.3 2.7Unsafe 4.7 4.0
% Safe 53.7% 33.8%
Tying sutures
Safe 3.5 1.5Unsafe 0.5 1.0% Safe 86.9% 25.6%
Tissue retraction
Safe 1.8 0.8Unsafe 0.5 0.8% Safe 83.3% 28.3%
Injection needle handling
Safe 0.4 0.5Unsafe 0.2 0.5% Safe 72.2% 44.1%
Overall Personal Sharps Tasks % Safe 66.3% 23.1%
Table 2. Summary of safe and unsafe personal sharps tasks for all initial videos of surgical residents (n=19).
RESULTSRESULTS19 surgical residents videoed
15 general surgery residents (PGY-2) 4 plastic surgery residents (PGY-1)
Initial videos (n=19): Sharps tasks performed safely = 66.3% Safe passing of sharps = 90.4% Verbal notification when passing = 10.1% Unsafe sharps practices mostly with handling of
suture needle 4.7 unsafe actions per surgery All residents demonstrated safe handling of the
scalpel blade No actual injuries to the surgical resident/ team
Second video follow-up (n=8) No statistically significant differences between initial
and final procedures with regards to Personal sharps tasks (p=0.17), Passing of sharps instruments (p=0.14) or Verbal notification (p=0.29)
4.4 missed opportunities to use of verbal cues to alert team members when passing sharp instruments (SD=1.2)
DISCUSSIONDISCUSSIONJunior surgical residents consistently passed sharp instruments in a safe mannerTasks relating to manipulation of sharps were less likely to be performed safelyMinority of residents verbally notified team members when passing sharp instrumentsReview of technical performance of the surgical procedure did not significantly improve safe sharps handling practices
Explicit instruction and feedback on sharps handling should Explicit instruction and feedback on sharps handling should become an integral part of surgical residency programs and become an integral part of surgical residency programs and surgical culture (4-7)surgical culture (4-7)
Figure 1. Examples of safe and unsafe manipulation of the suture needle. 1) Unsafe handling of suture needle using fingers. 2) Safe handling of suture needle using forceps.
METHODSMETHODSJunior surgical residents:
PGY-2 general surgery & PGY-1 plastic surgery residents 2 month rotation in pediatric general pediatric surgery at BC
Children’s Hospital in Vancouver, British Columbia Videotaped performing pediatric indirect inguinal hernia repairs:
Junior surgical residents as principle operator, attending surgeon assisting
Technical feedback was given by the attending surgeon on review of the videotape footage with resident
Residents were not given specific feedback on sharps handling technique
Safe/unsafe practices Based on the Association of Perioperative Nurses and the
American College of Surgeons guidelines (4,7). Videos reviewed, each sharp episode judged “safe” or “unsafe”
(4) Association of periOperative Registered Nurses. AORN guidance statement: sharps injury prevention in the perioperative setting. AORN J. 2005 Mar;81(3):662, 665-6, 669-71. (5) Camilleri AE, Murray S, Squair JL, Imrie CW. Epidemiology of sharps accidents in general surgery. J.R.Coll.Surg.Edinb. 1991 Oct;36(5):314-316. (6) Brasel KJ, Mol C, Kolker A, Weigelt JA. Needlesticks and surgical residents: who is most at risk? J.Surg.Educ. 2007 Nov-Dec;64(6):395-398. (7) Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J.Am.Coll.Surg. 2004 Sep;199(3):462-467.
RESULTSRESULTS